| Summary: | Significance & Background: Intravenous extravasation, the leakage of vesicant medications into surrounding tissue, poses serious risks to oncology patients. Chemotherapy extravasation events are rare, with national benchmarks reporting rates of less than 1%, and 0.3 - 4.7% of those events occurring in Central Venous Access Devices (CVADs). An extravasation event involving enfortumab vedotin administration via an implanted port prompted a comprehensive investigation. Purpose: The purpose of this project was to identify contributing factors and implement health system-wide countermeasures following an implanted port extravasation, with the goal of improving vascular access safety and improving nursing implanted port care competency. Interventions: A multidisciplinary team was assembled to investigate the event. Root causes included post-implanted port placement site swelling, large body habitus, inadequate needle length, uncertain blood return, and documentation gaps. Countermeasures were deployed at micro- and macro-system levels, including: Clinic-Wide: infusion nurse education, policy reminders, chart audits, and competency reviews; Oncology Division-Wide: escalation flowcharts, implanted port assessment algorithms, clinical rounds, and training material reviews; and Health System-Wide: tip sheets, training videos, electronic health record flowsheet updates, and dissemination via newsletters and committees. Results: Resources were shared across oncology clinics and committees, and health system committees, including the nursing leadership council. Oncology-specific modules are in process of being created, and implanted port-specific competencies have been added to annual revalidation and hands-on checkoffs for oncology infusion clinics. Compliance is monitored through audits and dashboards. No further extravasation events involving implanted ports have occurred. Discussion: Early detection of care deviations, standardized escalation protocols, and competency validation are important in preventing CVAD-related harms. Nurses play a critical role in implanted port assessment and medication administration. The event catalyzed system-wide improvements in vascular access safety and education. Awareness of the vesicant-like properties of enfortumab vedotin has been shared broadly. Ensuring competency, clear documentation, and timely escalation can mitigate risks of harm and improve patient outcomes. The interventions from this event investigation offer a model that may be replicated by other institutions.
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